Allergic Rhinitis (Hay Fever)
Allergies, including allergic rhinitis, affect an estimated 40 million to 50 million people in the United States. Some allergies may interfere with day-to-day activities or lessen the quality of life.
Rhinitis is a term describing the symptoms produced by nasal irritation or inflammation. Symptoms of rhinitis are due to blockage or congestion. They include:
- Runny nose
- Stuffy nose due to blockage or congestion
These symptoms are the nose's natural response to inflammation and irritation. They are often associated with itching of the eyes.
The nose normally produces mucus to trap substances (like dust, pollen and pollution) and germs (bacteria and viruses). Mucus flows from the front of the nose and drains down the back of the throat. When too much mucus is made, it can cause a runny nose from the front or post-nasal drip from the back. Cough is the natural response to clearing the throat from post-nasal drip.
Itching, sneezing, and other symptoms can be responses to:
- Allergic reactions
- Chemical exposures including cigarette smoke
- Temperature changes
- Other factors
In most people, nasal congestion goes from side to side of the nose in a cycle several hours long. Some people may notice this nasal cycle more than others, especially if their nasal passages are narrow. Strenuous exercise or changes in head position can affect nasal congestion. Severe congestion can result in facial pressure and pain, as well as dark circles under the eyes.
When no specific cure is available for your chronic rhinitis, options include ignoring your symptoms, avoiding or decreasing exposure to irritants or allergens to the extent practical, and taking medications for symptom relief.
Once allergic rhinitis is diagnosed, treatment options include avoidance, medication and immunotherapy (allergy shots).
Avoidance - A single ragweed plant may release 1 million pollen grains in just one day. The pollen from ragweed, grasses and trees is so small that the wind may carry it miles from its source. Mold spores, which grow outdoors in fields and on dead leaves, also are everywhere and may outnumber pollen grains in the air even when the pollen season is at its worst.
While it's difficult to escape pollen and molds, here are some ways to lessen exposure.
- Keep windows closed and use air-conditioning in the summer, if possible. Automobile air conditioners help, too.
- Don't hang clothing outdoors to dry. Pollen may cling to towels and sheets.
- The outdoor air usually is most heavily saturated with pollen and mold between 5 a.m. and 10 a.m., so early morning is a good time to limit outdoor activities.
- Wear a pollen mask (such as a NIOSH rated 95 filter mask) when mowing the lawn, raking leaves or gardening, and take appropriate medication beforehand.
Medication - When avoidance measures don't control symptoms, medication may be the answer. Medications help to reduce nasal congestion, runny nose, sneezing and itching. They are available in many forms, including tablets, nasal sprays, eye drops and liquids.
What is sinusitis?
Sinusitis is inflammation or infection of any of the four groups of sinus cavities in the skull, which open into the nasal passages. Sinusitis is not the same as rhinitis, although the two may be associated, and their symptoms may be similar. The terms "sinus trouble" or "sinus congestion" are sometimes wrongly used to mean congestion of the nasal passage.
What is allergic rhinitis?
Known to most people as hay fever, allergic rhinitis is a very common medical problem affecting more than 15 percent of adults and children.
Allergic rhinitis takes two different forms:
- Seasonal: Symptoms of seasonal allergic rhinitis occur in spring, summer and/or early fall. They are usually caused by allergic sensitivity to pollens from trees, grasses or weeds, or to airborne mold spores.
- Perennial: People with perennial allergic rhinitis experience symptoms year-round. It is generally caused by sensitivity to house dust mites, animal dander, cockroaches and/or mold spores. Underlying or hidden food allergies rarely cause perennial nasal symptoms.
Some people may experience both types of rhinitis, with perennial symptoms getting worse during specific pollen seasons. There are also non-allergic causes for rhinitis.
What causes the sneezing, itchy eyes and other symptoms?
When a sensitive person inhales an allergen (allergy-causing substance) like ragweed pollen, the body's immune system reacts abnormally. The allergen binds to allergic antibodies (immunoglobulin E, or IgE) that are attached to cells that produce histamine and other chemicals. The pollen "triggers" these cells in the nasal membranes, causing them to release histamine and the other chemicals. Histamine dilates the small blood vessels of the nose making fluids leak out into other tissues. This causes runny noses, watery eyes, itching, swelling and other allergy symptoms.
Antibodies circulate in the blood stream, and collect in the tissues of the nose and in the skin. This makes it possible to show the presence of these antibodies by skin testing, or less commonly, by a special IgE allergy blood test. A positive skin test mirrors the type of reaction going on in the nose.
No hay, no fever, so why "hay fever"?
"Hay fever" is a century-old term that has come to describe the symptoms of allergic rhinitis, especially when it occurs in the late summer. However, the symptoms are not caused by hay (ragweed is one of the main culprits) and are not accompanied by fever. So, the term "allergic rhinitis" is more accurate. Similarly, springtime symptoms are sometimes called "rose fever," but it's just coincidental that roses are in full-bloom during the grass-pollinating season. Roses and other sweet-smelling, showy flowers rely on bees, not the wind, for pollination. Not much of their pollen gets into the air to cause allergies.
Is there any escape?
A common question from allergic rhinitis sufferers is: Can I move someplace where my allergies will go away? Some allergens are tough to escape. Ragweed, which affects 75 percent of allergic rhinitis sufferers, blankets most of the United States. Less ragweed is found in a band along the West Coast, the southern-most tip of Florida and northern Maine, but it is still present. Even parts of Alaska and Hawaii have a little ragweed.
Allergists seldom recommend moving to another locale as a cure for allergies. A person may escape one allergy to ragweed, for example, only to develop sensitivity to grasses or other allergens in the new location. Since moving can have a disrupting effect on a family financially and emotionally, relocation should be considered only in an extreme situation and only after consultation with an allergist.
Can allergic rhinitis cause other problems?
Some known complications include ear infections, sinusitis, recurrent sore throats, cough, headache, altered sleep patterns, fatigue, irritability and poor school performance. Occasionally, children may develop altered facial growth and orthodontic problems.
Are all cases of rhinitis caused by allergy?
Rhinitis may result from many causes other than allergy. Not all rhinitis symptoms are the result of allergies. Below are listed the three most common causes of rhinitis with some of their characteristics.
Duration Of Symptoms
Dust mites, animals, pollens, molds, cockroaches
Perennial and/or seasonal
Colds or flu
Three to seven days, sometimes longer
Smoke, air pollution, exhaust fumes, aerosol sprays, fragrance, paint fumes, etc.
Perennial and/or following exposure
The most common condition causing rhinitis is the common cold, an example of infectious rhinitis. Most infections are relatively short-lived, with symptoms improving at three to seven days. Colds can be caused by any one of more than 200 viruses. Children, particularly young children in school or day care centers, may have from eight to 12 colds each year. Fortunately, the frequency of colds lessens after immunity has been produced from exposure to many viruses.
Colds usually begin with a sensation of congestion, rapidly followed by runny nose and sneezing. Over the next few days, congestion becomes worse, the nasal mucus may become colored, and there may be a slight fever and cough. Cold symptoms go away within a couple of weeks, although a cough may sometimes persist. Cold symptoms that last longer may be due to other causes, such as non-infectious rhinitis or sinusitis.
What are other causes of rhinitis?
Not all hay fever symptoms in the nasal passage are caused by allergy or infection. Similar symptoms can be caused by mechanical blockage, use of certain medications, irritants, temperature changes or other physical factors. In fact, one third or more of people who have year-round nose symptoms do not have allergies. Rhinitis can also be a feature of other diseases and medical conditions.
Drug-induced nasal congestion can be caused by birth control pills and other female hormone preparations, certain blood pressure medications, and prolonged use of over-the-counter decongestant nasal sprays.
Decongestant nasal sprays work quickly and effectively, but they change how the nasal passages normally work. After a few weeks of use, nasal tissues swell after the medication wears off. The only thing that seems to relieve the obstruction is more of the medicine, but the medication's effect lasts shorter lengths of time. Permanent damage to the nasal tissues may result. The medical term for this condition is rhinitis medicamentosa. Consultation with a physician and prescription medication to "get off" the decongestant nasal sprays is often necessary.
What triggers non-allergic rhinitis?
Non-allergic rhinitis, or vasomotor rhinitis, describes a group of other causes of rhinitis, with symptoms not caused by infection or allergy. Many people have recurrent or chronic nasal congestion, excess mucus production, itching, and other nasal symptoms similar to those of allergic rhinitis, but the disorder is not caused by allergy.
Triggers of non-allergic rhinitis include:
- Irritants such as cigarette smoke, strong odors and fumes, including perfume, hair spray, other cosmetics, laundry detergents, cleaning solutions, pool chlorine, car exhaust and other air pollution.
- Spices used in cooking, alcoholic beverages (particularly beer and wine), aspirin and certain blood pressure medications.
- In some people, eating any foods (whether or not they are spicy) can cause nasal drainage because of a non-allergic nerve reflex. The medical term for this is gustatory rhinitis.
- Some people are very sensitive to sudden changes in weather or temperature. Skiers often develop a runny nose, but in some people any cold exposure may cause a runny nose. Others start sneezing when leaving a cold, air-conditioned room.
These factors are not allergens, do not induce formation of allergic antibodies, and do not produce positive skin test reactions. Occasionally, one or two positive skin tests may be observed, but they do not match with the history and are not relevant or significant.
The causes of non-allergic rhinitis are not well understood. In high enough concentrations, many odors will cause nasal irritation in almost anyone. Some people are unusually sensitive to irritation and will develop nasal symptoms even when exposed to low concentrations of irritants that do not bother most people.
As is the case with allergic rhinitis, non-allergic rhinitis often can't be cured. Fortunately, symptoms can be kept under control by limiting exposure to substances that cause symptoms and by taking medication when needed. Patients with non-allergic rhinitis should not smoke or permit smoking in their homes.
Dryness of the nasal tissues can be a normal effect of aging, or a characteristic of a nasal condition associated with a foul smelling nasal discharge. Rhinitis can also result from some hormonal factors, such as under-active thyroid or hormone changes during pregnancy. However, pregnancy can either make rhinitis worse or better, or have no effect. Alcoholic beverages can cause the blood vessels in the nose to enlarge temporarily and produce significant nasal congestion.
Hay Fever Treatment
When allergy symptoms are not well controlled with avoidance measures, allergy medications can help to reduce nasal congestion, runny nose, sneezing and itching. They are available in many forms, including oral tablets, liquid medication, nasal sprays, and eye drops.
Intranasal corticosteroids are the single most effective drug class for allergic rhinitis treatment. They can significantly reduce nasal congestion as well as sneezing, itching and runny nose. These drugs are frequently prescribed, and are of particular value when rhinitis symptoms are more severe. They are most effective when taken daily, but may have some benefit when taken as needed.
These medications are safe when used under physician supervision. They are designed to avoid the side effects that may occur from steroids when they are taken by mouth or injection. However, care must be taken not to spray them against the center portion of the nose (the nasal septum). The most common side effects are local irritation and nasal bleeding. Some older preparations have been shown to have some effect on children's growth, but data about some newer nasal steroids have not shown an effect on growth.
Antihistamines are inexpensive and commonly used to treat allergic rhinitis. These medications counter the effects of histamine, the irritating chemical released within your body when an allergic reaction takes place. Although other chemicals are involved, histamine is primarily responsible for causing the symptoms.
Antihistamines do not cure, but help relieve nasal allergy symptoms such as:
- Sneezing, itchy, and runny nose
- Eye itching, burning, tearing and redness
- Itchy skin, hives, and eczema
- Certain other allergic conditions.
There are dozens of different antihistamines and wide variations in how patients respond to them. Some are available over-the-counter and others require a prescription.
Generally, the newer (second generation) products work well and produce only minor side effects. Some people find that an antihistamine becomes less effective as the allergy season worsens or their allergies change over time.
Short-acting antihistamines can be taken every four to six hours, while timed-release antihistamines are taken every 12 to 24 hours. The short-acting antihistamines are often most helpful taken 30 minutes before an anticipated allergic exposure (such as a picnic during ragweed season). Timed-release antihistamines are better suited to chronic (long-term) use for those who need daily medications.
Proper use of these drugs is just as important as their selection. The most effective way to use them is before symptoms develop. A dose taken early can eliminate the need for many later doses to reduce established symptoms. Many times a patient will say that he "took one, and it didn't work." If he or she had taken the antihistamine regularly for three to four days, and built up blood levels, it might have been effective.
Older (first generation) antihistamines may cause drowsiness and/or performance impairment, which can lead to accidents and personal injury. Even when these medications are taken only at bedtime, they can still cause considerable impairment the following day. Impairment can occur even in people who do not feel drowsy. For this reason, it is important that you do not drive a car or work with dangerous machinery when you take a potentially sedating antihistamine. Some of the newer antihistamines do not cause drowsiness.
Another frequently encountered side effect is excessive dryness of the mouth, nose and eyes. Less common side effects include restlessness, nervousness, over excitability, insomnia, dizziness, headaches, euphoria, fainting, visual disturbances, decreased appetite, nausea, vomiting, abdominal distress, constipation, diarrhea, increased or decreased urination, urinary retention, high or low blood pressure, nightmares (especially in children), sore throat, unusual bleeding or bruising, chest tightness or palpitations. Men with prostate enlargement may encounter urinary problems while on antihistamines.
Alcohol and tranquilizers increase the sedation side effects of antihistamines.
- Never take anyone else's medication.
- Do not use more than one antihistamine at a time, unless prescribed.
- Keep these medications out of the reach of children.
- Know the effect of the medication on you before working with heavy machinery, driving or doing other performance-intensive tasks; some products can slow your "reaction time."
- Follow your physician's instructions.
Some antihistamines appear to be safe, but there have not been enough studies to determine absolute safety of antihistamines in pregnancy. Again, consult your allergist or obstetrician if antihistamines must be taken.
While antihistamines have been taken safely by millions of people in the last 50 years, don't take antihistamines before telling your allergist if you are allergic to or intolerant of any medicine; are pregnant or intend to become pregnant while using this medication; are breast feeding; have glaucoma or enlarged prostate; or have any medical illness.
Decongestants help relieve the stuffiness and pressure caused by swollen nasal tissue. They do not contain antihistamines, so they do not cause antihistamiic side effects. They do not relieve the other symptoms of allergic rhinitis, such as runny nose, post-nasal drip and sneezing. Decongestants are available as prescription and non-prescription medications and are often seen in combination with antihistamines or other medications. It is not uncommon for patients using decongestants to experience insomnia if taking the medication in the afternoon or evening. If this occurs, a dose reduction may be needed.
At times, men with prostate enlargement may encounter urinary problems while on decongestants. Patients using medications for the management of emotional or behavioral problems should discuss this with their physicians before using decongestants. Pregnant patients should also check with their physician before starting decongestants.
Non-prescription decongestant nasal sprays
work within minutes and last for hours, but should not be used for more than a few days at a time without a physician's order. Prolonged use can cause rhinitis medicamentosa, or rebound swelling of the nasal tissue. Stopping the use of the decongestant nasal spray will cure rhinitis medicamentosa, providing that there is no underlying disorder.
are found in many over-the-counter and prescription medications, and may be the treatment of choice for nasal congestion. They don't cause rhinitis medicamentosa but need to be avoided by some patients with high blood pressure. If you have high blood pressure, you should check with your physician before using them.
Non-prescription saline nasal sprays
will help counteract symptoms of dry nasal passages or thick nasal mucus. Unlike decongestant nose sprays, a saline nose spray can be used as often as needed. Sometimes, your physician may recommend washing (douching) of the nasal passage. There are many over the counter preparations for saline rinses, including neti- pots and saline rinse bottles.
is a medication that blocks the body's release of allergy-causing substances. It does not work in all patients. The full dosage is four times daily, and improvement may take several weeks to occur. Nasal cromolyn can help prevent allergic nasal reactions if taken prior to an allergen exposure.
Nasal ipratropium bromide spray (Atrovent)
can help reduce nasal drainage from allergic rhinitis or some forms of non-allergic rhinitis.
is a tablet medication approved for treatment of allergic rhinitis, as well as asthma. It works against substances called leukotrienes that can cause symptoms of allergic rhinitis.
are for the treatment of bacterial infections. They do not affect the course of uncomplicated common colds and are of no benefit for non-infectious rhinitis, including allergic rhinitis.
- Allergen immunotherapy, known as "allergy shots," may be recommended for persons who don't respond well to treatment with medications, experience side effects from medications, who have allergen exposure that is unavoidable, or desire a more permanent solution to their allergic problem. Immunotherapy can be very effective in controlling allergic symptoms. Immunotherapy does not help the symptoms produced by non-allergic rhinitis.
Allergy injections are usually given at variable intervals over a period of three to five years. An immunotherapy treatment program consists of injections of a diluted allergy extract, administered frequently in increasing doses until a maintenance dose is reached. Then, the injection schedule is changed so that the same dose is given with longer intervals between injections. Immunotherapy helps the body build resistance to the effects of the allergen, reduces the intensity of symptoms caused by allergen exposure, and sometimes can actually make skin test reactions disappear. As resistance develops, symptoms should improve, but the improvement from immunotherapy will take several months to occur.
is of no benefit in allergic rhinitis, but it may help if patients have nasal polyps or chronic sinusitis not responsive to prolonged antibiotics and nasal steroid sprays.
Allergic Diseases and Cognitive Impairment
Sneezing, wheezing, watery eyes and runny nose aren't the only symptoms of allergic diseases. Many people with allergic rhinitis also report feeling "slower" and drowsy. When their allergies are acting up, they have trouble concentrating and remembering.
For instance, allergic rhinitis can be associated with:
- Decreased ability to concentrate and function
- Activity limitation
- Decreased decision-making capacity
- Impaired hand-eye coordination
- Problems remembering things
- Sleep disorders
- Missed days at work or school
- More motor vehicle accidents
- More school or work injuries
Many parents of children with allergic rhinitis observe increased bad moods and irritability in their child's behavior during the allergy season. Since children cannot always express their uncomfortable or painful symptoms verbally, they may express their discomfort by acting up at school and at home. In addition, some kids feel that having an allergic disease is a stigma that separates them from other kids.
It is important that the irritability or other symptoms caused by ear, nose or throat trouble are not mistaken for attention deficit disorder. With proper treatment, symptoms can be kept under control and disruptions in learning and behavior can be avoided.
Experts believe the top two culprits contributing to cognitive impairment of people with allergic rhinitis are sleep interruptions and sedating antihistamine (OTC) medications.
Secondary factors, such as blockage of the Eustachian tube (ear canal), also can cause hearing problems that have a negative impact on learning and comprehension. Constant nose blowing and coughing can interrupt concentration and the learning process, and allergy-related absences can cause people to miss school or work and subsequently fall behind.
Chronic nasal congestion can cause difficulty in breathing, especially at night. Waking is a hard-wired reflex to make you start breathing again. If you have bad allergic rhinitis, you may waken a dozen times a night. Falling back asleep can be difficult, cutting your total number of sleep hours short.
The average person needs about eight hours of sleep per night to function normally the next day. Losing just a few hours of sleep can lead to a significant decrease in your ability to function. Prolonged loss of sleep can cause difficulty in concentration, inability to remember things, and can contribute to automotive accidents. Night after night of interrupted sleep can cause serious decreases in learning ability and performance in school or on the job.
Most allergy therapies don't take into account the effects of allergic rhinitis on mental functioning - they treat the more obvious physical symptoms. Some allergy therapies may even cause some cognitive or mental impairment.
In a recent poll in which allergy sufferers were asked how they treat their symptoms, about 50 percent responded that they use over-the-counter (OTC) medications. The most commonly used OTC medications for allergy symptoms are decongestants and first generation antihistamines, such as diphenhydramine (Benadryl¨) - both of which can cause sleep disturbances.
Decongestants constrict small blood vessels in the nose. This opens the nasal passageways and lets you breathe easier. Some decongestants are available over-the-counter, while higher strength formulas are available with a prescription. In some people, oral decongestants can cause problems with getting to sleep, appetite loss and irritability, which can contribute to allergy problems. If you have any of these symptoms, discuss them with your doctor.
Antihistamines block the effects of histamine, a chemical produced by the body in response to allergens. Histamine is responsible for the symptoms of allergic rhinitis, including an itchy runny nose, sneezing and itchy eyes. First generation OTC antihistamines available in the United States also can cause drowsiness. Regularly taking OTC antihistamines can lead to a feeling of constant sluggishness, affecting learning, memory and performance.
Newer second generation antihistamines such as Claritin (loratadine) and Zyrtec¨(cetirizine) which are OTC and Clarinex¨ (desloratadine), Allegra(r) (fexofenadine), Xyzal (levocetirizine¨) by prescription are non or low sedating are designed to minimize drowsiness while still blocking the effects of histamine.
With all the allergic diseases, the best way to control your symptoms is to avoid coming into contact with your triggers - the substances that cause you to have an allergic reaction. This is often easier said than done. Sometimes it is impossible to avoid the substances that cause symptoms, especially when you are not in control of your environment.
If your allergens can't be avoided, we can help you to create an allergy treatment plan. People who are allergic to indoor things like dust mites or animal dander may need medication on a daily basis, while people who have seasonal symptoms may only need treatment at certain times during the year.
Several types of non-sedating medications are available to help control allergies. One nonsedating nasal spray, NasalCrom (cromolyn), is available without a prescription. Your doctor may also prescribe nasal steroid sprays to treat nasal inflammation. Nasal steroid sprays are highly effective in treating allergy symptoms. The most common side effect associated with nasal sprays is headache.
If medications are not effective or cause unwanted side effects, your doctor may suggest immunotherapy, or "allergy shots". Immunotherapy is used to treat allergy to pollen, ragweed, dust mites, animal dander and other allergens. This process gradually desensitizes you to these substances by changing the way that your body's immune system responds to them. For example, if you are allergic to ragweed, immunotherapy treatments would involve injecting a tiny amount of ragweed pollen extract under your skin every week. Immunotherapy treatments usually last three to five years or longer. Once your body is able to tolerate the substance without producing the symptoms of an allergy, immunotherapy can be stopped, and the need for oral medications should be gone or greatly reduced.
If allergies are affecting your ability to concentrate or function, several treatment options may be beneficial. Getting allergy symptoms under control can help you sleep at night and function during the day.
If you suspect that you or a family member may have an allergic disorder, make an appointment with your doctor for proper diagnosis. Treating allergies sooner rather than later can help prevent disruptions in learning and behavior.